Abdominal Flashcards
On general inspection in chronic liver disease
Malnourished
Bruising (impaired clotting)
abdominal distension
jaundince if obvious
Hands/Arms in chronic liver disease
CLubbing Palmar erythema Dupuytren's contracture (alcohol) Liver flap in hepatic encephalopathy Leukonychia due to hypoalbuminemia Koilonychia due to low iron
eyes/FACE in chronic liver disease
Jaundiced sclera if decompensated
ANEMIA
Parotid enlargement if liver failure cuased by EtOH
Neck in chronic liver disease
raised JVP due to fluid overload secondary to hypoalbuminemia
chest in chronic liver disease
reduced hair
gynaecomastia
spider naevi
causes of nail clubbing (ABDO)
IBD, especially Chron’s
cirrhosis
coeliac
hand signs in chronic liver disease
leuconychia
palmar erythema
dupuytren’s in EtOH
CAUSES OF ABDOMINAL DISTENSION
Flatus Faeces Fetus Fat Fluid (ascites, ovarian cyst)
characteristics of spleen
- in the right hypochondrium
- has a notch
- cannot get above it
- moves on respiration
- dull to percussion
causes of splenomegaly
Infection: viral (EBV), bacterial, protozoal (malaria, schisstosomiasis), parasitic (Hydatid)
Haematological: (LYMPHOPROLIFERATIVE AND MYELOPROLIFERATIVE) leukemia (CLL/CML),lymphoma, myelofibrosis, polycythemia, haemolytic anaemia
Portal HTN
Autoimmune: SLE, Rheumatoid arthritis (Felty’s)
Sarcoid,
Metabolic: amyloid, storage diseases
CYsts
MUST MAKE POINT TO CHECK ALL THE LYMPH NODES
Causes of hepatomegaly
RHF: smooth, tender, large, +/-pulsatile (tricuspid regurg), raised JVP
Infection: EBV, hepatitis, malaria
Malignancy: mets or primary, myeloma, leukaemia, lymphoma
Others: sickle cell disease, porphyria
MUST MAKE POINT TO CHECK ALL THE LYMPH NODES
Polycystic kidney disease findings
Bilateral, irregular abdominal masses
1/3 have cysts in liver, pancreas
Increased blood pressure (clues» Betablockers?)
+/-AV fistulae/ rutherford-morrison scar for kidney transplant/scar in the abdomen
FBC (↑Hb) U+Es(↑urea), US abdo, screen family members
CT head for berry aneurysms
Renal mass DDx
polycystic kidney disease renal cyst renal malignancy hydronephrosis pyelonephrosis perinephric abscess renal TB Rena cell carcinoma (male >40 years)
general inspection in IBD findings
hands
face/mouth
Legs
CUshingoid appearance from steroids Nail clubbing Leuconychia/koilonychia Mouth ulcers Skin/eye inflammation
Pyoderma gangrenosum
Erythema nodosum
What are Terru’s nails?
signify chronic liver disease
They are white proximally but dark red distally
Causes of palpable liver without hepatomegaly?
Lung hyperinflation (eg in COPD) Riedel's lobe Gallbladder pathology
When does spleen become palpable?
At least twice its size
Key features of portal HTN
- ascites
- splenomegaly
- caput medusae
- oesophageal varices
Lump examinations
- Site • Texture • Fixed/ mobile
- Size • Tenderness • Pulsatility
- Shape • Transillumination • Consistency
commonest non-fatal condition causing splenomegaly and jaundice
hereditary spherocytosis
General features in renal transplant
Signs of previous renal replacement therapy (forearm fistula or PD scar)
Evidence of immunosuppression (gum hypertrophy (ciclosporin), cushingoid appearance, skin tumours))
Mass in the iliac fossa, with overlying J shaped scar
Causes of ESRF in the UK
Diabetes Glomerulonephritis CHronic pyelonephritis Polycystic kidneys Interstitial nephritis HTN
DDX for masses in iliac fossa
Chron's disease Primary malignancy Iliac TB Appendicular abscess Caecal carcinoid
How would you define jaundice?
Jaundice is the yellowish discolouration of the skin, sclera and mucous membranes due to hyperbilirubinaemia
How is bilirubin produced?
#Bilirubin is the end product of haem metabolism 80% of bilirubin is produced from the breakdown from haemobglobin in RBCs and 20% from the breakdown of haem in myoglobin and cytochromes.
What causes jaundice?
The causes can be classified as Pre-hepatic , hepatic and post-hepatic causes.
Prehepatic: when bilirubin production is increased through exercise, haemoglobin breakdown (haemolysis) or myoglobin breakdown (rhabdomyolisis). Haemolysis can be intrinsic where the RBC is defective or extrinsic, where RBC is normal.
Hepatic: bilirubin increases in any process in which cell necrosis reduces liver’s ability to metabolize and excrete bilirubin such as:
Acute hepatitis and liver cirrhosis of any cause, enzymopathies such as Gilbert’s syndrome and Crigler-Najjar syndrome.
Posthepatic: when there is an obstruction of biliary drainage system causing their reflux to blood. Within the liver: PBC, PSC, drugs. Extrahepatically: gallstones, pancreatic Ca, parasites.
How would you investigate patients with jaundice?
FBC, LFTs, hepatoglobulins, reticulocytes, coom’s test, clotting profile, autoimmune screen, viral screen. Urine test. Further: USS abdo, CT abdo, ERCP, MRCP, liver biopsy
What is Gilbert’s syndrome?
Autosomal dominant condition resulting in reduced levels of the enzyme glucuronyltransferase. This results in reduced conjugation of bilirubin.→ lvls of unconjugated bilirubin ↑. Precipitated by stress, fasting, infection. Condition is benign and asymptomatic, no treatment necessary.##What is Dubin-Johnson syndrome?
Autosomal recessive defect in molecular transporters responsible for excreting conjugated bilirubin out of hepatic cells. → ↑levels of conjugated bilirubin and pigmentation of the liver
Physical findings in chronic lliver disease
Findings:
Jaundice
Hands: clubbing, leuconychia, hyperpigmentation, excortiation, purpura, xantomata, dupytren;s contracture, palmar erythema, hepatic flap
Trunk: hepato-, spelno-megaly, ascites, caput medusa, spider naevi, gynaecomastia
Other: scanty body hair, testicular atrophy, ankle oedema, tattoos, needle marks →? IVDU
Cirrhosis is what?
It’s a consequence of chronic liver disease. Characterised by a replacement of normal liver tissue by fibrous scar tissue and regenerative nodules, which leads to a loss of liver function.
Complications of liver cirrhosis?
Ascites Spontaneous bacterial peritonitis Coagulopathy Portal HTN Hepatic encephalopathy Hepatorenal syndrome HCC
What can precipitate hepatic encephalopthy>
Infection Drugs: diuretics and sedatives Upper GI bleed Abdo paracentesis Surgery
What is autoimmune hepatitis?
More common in females. Associated with autoimmune conditions such as type 1 diabetes, thyroiditis, RA, scleroderma, IBD.
Presents with fatigue, RUQ pain, arthralgia, abnormal LFTs
Tx with immunosuppressive drugs (steroids, azathioprine)
80% are associated with HLA B8/DRw£, ANA, anti-smooth muscle antibodies and polyclonal hypergammaglobulinaemia.
Alpha-1-antitrypsin deficiency is what?
Defective production of alpha-1-antitrypsin, which is a protease inhibitor. There are several forms and degrees of deficiency. Deficiency results in cirrhosis, increased risk of HCC, emphysema. Tx by liver and lung transplantation.
What is hep B virus?
It is a DNA virus
Transmitted perenterally or by sexual contact. Complications include liver cirrhosis and HCC. Tx with interferon-alpha is successful in about 40% of cases. SEs include flu-like sx, depression, fatigue, haematological abnormalities. Other drugs: lamivudine, adefovir, entecavir.
What is hep C virus?
It is an RNA virus. Main routes of transmission: through needles in IVDU, blood transfusions, blood products. Sexual transmission is low. Complicaitons: liver cirrhosis, HCC. Tx: interferon-alpha and ribavarin.
When can liver be palpable without being enlarged?
Emphysema – overinflated lungs#
Reidel’s lobe
R-sided pleural effusion
What is Budd-Chiari syndrome?
Characterised by thrombosis of the hepatic veins, resulting in: abdo pain, ascites, hepatomegaly
Jaundice usually absent
No cutaneus features of liver disease as the onset of liver failure is rapid
Liver is smoothly enlarged and tender
What are the causes of Budd-Chiari?
Hypercoagulabloe states: pregnancy, contraceptive pill, PRV, essential thrombocythaemia, antiphospholipid syndrome, Protein C, S or antithrombin III deficiency
HCC
Hepatic infections such as hydatid disease
Renal and adrenal tumours
Congenital venous webs
What do you want to do if you fin splenomegaly?
I would like to complete my examination by CHECKING FOR LYMPHADENOPATHY IN THE AXILLAE, CERVICAL AND INGUINAL AREAS.
